A.
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GENERAL GUIDELINE OF VTE PROPHYLAXIS
Clinical judgment should always be used in utilizing the guideline.
References:
a.
b.
c.
d.
AAOS Clinical Guideline (Prevention of Symptomatic Pulmonary Embolism Guideline 2007)
MedQIC-Surgical Care Improvement Project. Specifications Manual for National Hospital Inpatient
Quality Measures. Discharges 10-01-08 (4Q08) through 03-31-09 (1Q09)
Prevention of venous thromboembolism: ACCP Evidence-Based Clinical Practice Guidelines (8th
edition) Chest 2008;133(6):381S-453S
Regional Anesthesia in the Anticoagulated patient: Defining the Risks (The Second American
Society of Regional Anesthesia Consensus Conference on Neuraxial Anesthesia and Anticoagulation).
Reg Aesth Pain Med 2003;28:172-197.
Abbreviations:
- Sequential Compression devices (SCD)
- Arterial Venous Impulse Boots (AVI)
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- Low-dose unfractionated heparin (LDUH)
- Low molecular weight heparin (LMWH)
- Central Venous Catheter (CVC)
1. Risk factor stratification is based on individual predisposing factors and the risk associated
with current illness or procedure
2. Mechanical Methods of Prophylaxis
 SCD or AVI alone or in combination with aspirin in orthopedic surgery patients with
documented high risk of bleeding is recommended
 SCD or AVI as an adjunct to anticoagulant-based prophylaxis
 Ensure correct size and application of the mechanical device, and optimal compliance
3. Neuraxial anesthesia/analgesia (NAA) [spinal or epidural anesthesia and continuous epidural
anesthesia]  Avoid neuraxial anesthesia/analgesia (NAA) in patients with a known bleeding disorder
 Avoid NAA in patients whose preoperative hemostasis is impaired by antithrombotic drugs
a. NSAID (generally safe)
b. Clopidogrel should be discontinued 5-14 days prior to NAA
 Needle insertion: at least 8-12 hours after a subcutaneous (SubQ) dose of unfractionated
heparin (UFH) or a twice daily prophylactic dose of low molecular weight heparin (LMWH),
or at least 18 hours after a once-daily dose of LMWH
 Needle removal: Remove an epidural catheter when the anticoagulant effect is at a
minimum just before the next scheduled SubQ injection
 Delay anticoagulant prophylaxis for at least 2 hours after spinal needle or epidural
catheter removal
 Delay anticoagulation if a hemorrhagic aspirate is encountered during the initial spinal
needle placement
 If on prophylaxis with warfarin, remove a catheter when INR <1.5
 Fondaparinux prophylaxis appears to be safe in patients who have received a spinal
anesthetic only if needle placement was atraumatic and accomplished on the first attempt,
but should be avoided with continuous epidural analgesia
B. VENOUS THROMBOEMOLISM RISK ASSESSMENT
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Acute medical illness
Age >65
Cancer (active or occult)
Cancer therapy (hormonal, chemo- or radiotherapy, angiogenesis inhibitors)
Estrogen-based OC or HRT
Erythropoiesis-stimulating agents
Immobility, lower-extremity paresis
Indwelling central venous catheter
Inflammatory bowel disease
Inherited or acquired thrombophilia
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Myeloproliferative disorders
Nephrotic syndrome
Obesity
Paroxysmal nocturnal hemoglobinuria
Pregnancy and post-partum period
Previous VTE
Selective estrogen receptor modulators
Surgery
Trauma (major or lower extremity)
Venous compression (tumor, hematoma, arterial
abnormality
This is not a permanent part of the medical record. Please discard after completing form.
C. VTE Prophylaxis Selection by Surgery
1
Patients who receive neuraxial anesthesia or have a documented contraindication to pharmacological prophylaxis may
pass the performance measure if either appropriate pharmacologic prophylaxis or mechanical prophylaxis is ordered.
2Recommendations are from the Specifications Manual for National Hospital Quality Measures 10-01-08 (4Q08) through 0331-09 (1Q09) SCIP-VTE 2-5. AAOS refers to the SCIP Guidelines for patients with high risk of bleeding.
Surgery
Recommended Prophylaxis1
Surgery
Recommended Prophylaxis1
Intracranial
Neurosurgery
Any of the following:
 SCD with
 LDUH
 LMWH
 LDUH or LMWH* combined with
SCD
*Current guidelines recommend
postoperative LMWH for Intracranial
Neurosurgery
Elective Total Hip
Replacement
Any of the following:
 LMWH
 Fondaparinux
 Warfarin
Elective Total Hip
Replacement with
contraindications to
pharmacological
prophylaxis
Any of the following:
 SCD
 AVI
 Any one of the above plus
aspirin2
Elective Total Knee
Replacement
Any of the following:
 LMWH
 Fondaparinux
 Warfarin
 SCD
 VFP
General
Surgery
General
Surgery with
high risk for
bleeding
Gynecologic
Surgery
Urologic
Surgery
Any of the following:
 LDUH
 LMWH
 Fondaparinux
 LDUH or LMWH or Fondaparinux
combined with SCD
Any of the following:
 SCD
Any of the following:
 LDUH
 LMWH
 Fondaparinux
 SCD
 LDUH or LMWH or Fondaparinux
combined with SCD
Any of the following:
 LDUH
 LMWH
 Fondaparinux
 SCD
 LDUH or LMWH or Fondaparinux
combined with SCD
Abbreviations:
- Sequential Compression devices (SCD)
- Arterial Venous Impulse Boots (AVI)
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Hip Fracture Surgery
Hip Fracture Surgery
with
contraindications to
pharmacological
prophylaxis
Any of the following:
 LDUH
 LMWH
 Fondaparinux
 Warfarin
Any of the following:
 SCD
 AVI
 Any one of the above plus
aspirin2
- Low-dose unfractionated heparin (LDUH)
- Low molecular weight heparin (LMWH)
- Central Venous Catheter (CVC)
This is not a permanent part of the medical record. Please discard after completing form.
Adult VTE Risk Assessment and Physician Order
Physician: Please check risk factor(s) below and order prophylaxis.
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Acute medical illness
Age >65
Cancer (active or occult)
Cancer therapy (hormonal, chemo- or
radio-therapy, angiogenesis inhibitors)
Estrogen-based OC or HRT
Erythropoiesis-stimulating agents
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 Inherited or acquired thrombophilia
 Immobility, lower-extremity paresis
 Indwelling central venous catheter
 Inflammatory bowel disease
Myeloproliferative disorder
Nephrotic syndrome
Obesity
Paroxysmal nocturnal hemoglobinuria
Pregnancy or post-partum period
Previous VTE
Selective estrogen receptor modulators
Surgery
Trauma (major or lower extremity)
Venous compression (Tumor, hematoma,
arterial abnormality
Pharmacological and Mechanical Prophylaxis Safety Assessment (Physician to check those that apply)
Pharmacological Prophylaxis Contraindication(s):
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Is patient experiencing any active bleeding?
Does patient have (or has had history of) heparin-induced thrombocytopenia?
Is patient’s platelet count <100,0003/mm?
Is patient already on anticoagulant therapy (warfarin, heparin, LMWH, or fondaparinux)?
Is patient’s creatinine clearance abnormal (<30 ml/min)? Fondaparinux is contraindicated.
Other:
If any of the above boxes are checked, the patient may not be a candidate for anticoagulant therapy.
Consider alternative prophylactic measures (mechanical prophylaxis) in Section B below.
B. Mechanical Prophylaxis Contraindications(s):
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Does patient have severe peripheral arterial disease?
Does patient have congestive heart failure (peripheral edema)?
Does patient have an acute superficial/deep vein thrombosis?
Does patient have skin conditions (dermatitis, open skin lesions, gangrenous condition, or lymphedema)?
Other:
If any of the above boxes are checked, then patient may not be a candidate for a sequential compression device.
Post-Op Physician’s Order (please check one):
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Prophylaxis is not indicated as checked above or other reason ___________________________________
________________________________________________________________________________
 Prophylaxis has already been ordered
 Place  SCD (Sequential Compression Device) or  AVI (Arterial Venous Impulse Boots)
AND  Aspirin 325 mg ______ daily
 For all post op surgical patients, start the first dose on the morning of POD one or as indicated below.
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Enoxaparin 40 mg SubQ daily, first dose at ___________. Pharmacy to adjust the dose, if CrCl < 30 ml/min.
Enoxaparin 30 mg SubQ twice daily, first dose at ___________. Pharmacy to adjust the dose, if CrCl < 30
ml/min.
Fondaparinux 2.5 mg SubQ daily, first dose at ___________. (contraindicated, if CrCl < 30 ml/min)
Unfractionated heparin 5000 units every 8 hours, first dose at ___________.
Warfarin ________ mg PO, first dose at ___________ and daily (until INR ______) and daily INR
Physician Signature
*0940770*
ID
Date
Adult VTE Risk Assessment & Physician Orders
Trial Form
Time